RIHFWK - Regional Institute of Health & Family Welfare, Kashmir

Training Programmes Under the Reproductive and Child Health Programme

The rapidly growing population has all along been a major concern for health planners and administrators in India. The country was the first to launch a national family planning programme in the world. However, within a mere 2 decades it dawned upon the policymakers and planners that the programme had become synonymous with birth control with its major emphasis on contraception. Various welfare components were the need of the hour. Across the globe, it was felt that parents like to keep additional children as a driver, uncertain about his car-tyres, would keep more spares with him. It was felt that unless the couples are ensured that all children, or most of them, will survive, they would never voluntarily opt for smaller families. This resulted in inclusion of various new programmes aimed at increasing the chances of child survival (Expanded Programme of Immunization, later rechristened the Universal Immunization Programme, Iodine Deficiency Disorder Programme, Vitamin A prophylaxis programme, Diarrhoea Disease Control Programme, Anaemia Prophylaxis Programme, etc). Maternal and child survival became the prime issue of the health planner. Soon , however, it was observed that all these programmes were administered separately which not only taxed the health providers but lead to unnecessary duplication of resources and efforts, and also caused inconvenience to the consumers. In order to ensure maximum benefit from various programmes and to provide services in an integrated manner to the vulnerable groups of expectant mothers and children, the Child Survival and Safe Motherhood (CSSM) programme, which was time bound for 5 years, was started in the year 1992.

However, despite all the sincere efforts, the desired impact on population growth and health and development of women and children in this country could not be achieved. This was because there was a mere integration of various programmes without any paradigm shift in the strategy or approach.

In 1994, the major shift came when, at the International Conference on Population and Development (ICPD), held at Cairo, the delegates recommended that a new approach needed to be adopted for tackling the problems of maternal and child health. Broadly speaking, it was decided that family welfare services should be provided as a component of comprehensive reproductive health care package.

There is now a general agreement that interventions needed to save the lives and preserve the health of mothers and babies cannot be implemented in a vertical and in-coordinated manner but must form part of a broader strategy to improve their overall health through primary health care. Much has been learnt about the technicalities of various interventions for maternal and child health and about the feasibility of implementing them in resource-poor settings. The new approach implies that different interventions should be applied holistically within a general health context that promotes equity in access to and quality of care. It has to be remembered that most pregnancy-related complications can be effectively prevented and managed without recourse to sophisticated and expensive technology or drugs. Experience has shown that maternal as well as neonatal mortality and morbidity are effectively reduced when communities are informed about various danger signs and when quality health services are available and easily accessible, including a referral system to manage complications at higher levels (secondary, tertiary) of the health care system.

RCH Programme: It is duly recognized that various health and welfare programmes helped to reduce the IMR fairly to our expectations (from 161 in 1965 to 71 now) but most of the first- year deaths remain concentrated in the neonatal period, especially early days. Also, there was almost no perceptible impact on maternal mortality rate. The RCH programme envisages effective implementation of various activities that would lead to a sustained improvement in maternal and new-born health. The programme was started on 15 th October 1997 and aims at achieving a status in which couples will be able to go through pregnancy and child-birth safely; the outcome of pregnancy will be an assured well-being and survival of the mother and her child; and couples will be able to have sexual relations which are free of the fear of pregnancy and contracting various sexually transmitted infections from each other. The concept is to provide to the beneficiaries integrated services which are need-based, client-centred, demand-driven and of high quality. While as maternal and child health components were part of the CSSM strategy also, two new components were added to the RCH programme ie the adolescent health services and management of reproductive tract infections, which were not covered by any other previously existing programme .

The provision of good quality care is the crux of RCH programme; greater emphasis is placed on quality of care than had been in the earlier programmes. The quality of services is improved, on the one hand, by providing services which are determined by the community itself (need assessment made by peripheral health workers with the families) and on the other hand, by enhancing the managerial capability of health care providers and augmenting the technical and professional acumen of the care-givers in the community. Thus training is helpful in enabling the district health staff in community needs assessment (initial, interim and end-stage), human resource development, resource management, maintenance and utilization of equipment, maintenance of records, and improving the two-way management information dissemination.

Reproductive and Child Health Programme.

Awareness Generation Training (AGT) under RCH for A Category

Programme Curriculum

Day 1

Registration, inauguration , pre-evaluation and introduction to the programme
Community needs assessment in relation to reproductive and child health programme
1. Reasons behind failure of National Family Welfare Programme
2. High birth rate and its significance
Needs, felt needs, unmet needs; community participation, bottom-to- top approach
Quality care under the RCH: assessment in health programmes; assessing efficiency of Programme Implementation in RCH
Essential neonatal care - role of TBA and the mid-wife; need for orientation in critical assessment of neonates; high-risk approach in neonatal care. Significance of neonatal mortality and post-neonatal IMR. Reasons behind high IMR, and means and methods to reduce high IMR.
Safe motherhood; interventions in RCH: Role of TBA, ANM and obstetrician; role of CHC, PHC and S/C. Significance of high MMR; causes of raised MMR; means and methods to reduce high MMR under RCH
Vaccine Preventable Diseases; immunization; AFP and eradication of poliomyelitis; cold chain maintenance and its significance for child survival

Day 2

The under-five child: Significance of U5MR; means and methods to reduce high under - five mortality; special reference to management of ARI and diarrhoeal diseases in the peripheries; role of private practitioners, MPW's and parents.
Adolescent health: problems and priorities; emphasis on adolescent health under RCH; Health, nutritional and sexual education of adolescents; role of inter-sectorial approaches (esp. Education, health, related- media)
Reproductive tract and sexually-transmitted infections; the syndromic approach for RTI and STI, role of the medical officer in the AD.
Management issues in RCH; Management cycle; management tiers; monitoring, supervision and evaluation; role of the middle and lower level managers in implementation of RCH
RCH concepts, objective, approaches and strategies; Different phases of maternal and child health care in India; evolution of RCH; augmentation of CHC's, PHC's and S/Cs under RCH; involving the hitherto untapped technical resources under RCH including private practitioners.
Post - programme evaluation

(Note: IEC component was part of each interaction; need and technique of counseling in RCH was highlighted by all resource persons.)

Training's under the programme The Training's under the RCH Programme are tri-phasic: The first phase was of the Awareness Generation Training where general awareness about the genesis and practicalities of the programme were given through a 2- day orientation of medical officers, paramedics and the non-governmental participants from voluntary and charitable societies. This phase was completed at our institute between April 2000 and June 2000, when 405 participants were oriented in 17 batches. This was followed by the integrated skill foundation courses, which began in January 2001 and are currently on. In the last year (ie 2001), a total of 168 medical officers participated in the training programme. In 2002 and 2003, an additional 66 and 60doctors were oriented bringing the total number to 294. Although the curriculum is broadly recommended by the National Institute of Health and Family Welfare, New Delhi, yet it is so flexible as to incorporate the changes as required for any local application. The participants are oriented at the RIHFW for a period of 7 days with the help of in-house and guest faculty and various trained facilitators, while as they pass 5 days in the 500–bedded tertiary-care women hospital (Lalded Hospital, Srinagar), and the 200-bedded Children Hospital for practical exposure and interaction with the faculty there, to get oriented with intricacies of good maternal and child care in the peripheries. The essential obstetric and the essential neonatal care, the practicalities of gross root childcare, and care of the infants and the under-fives is given due emphasis.